- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.34 / $6,232.95 / $7,084.73
| Professional | | $5,657.34 | $6,232.95 | $7,084.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.56 / $828.99 / $9,093.01
| Facility | | $673.56 | $828.99 | $9,093.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.56 / $725.37 / $9,792.46
| Professional | | $673.56 | $725.37 | $9,792.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $8,377.54
| Facility | | $7,860.06 | $7,860.06 | $8,377.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.44 / $7,860.06 / $7,860.06
| Professional | | $814.44 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.75 / $4,144.96 / $6,824.40
| Professional | | $2,922.75 | $4,144.96 | $6,824.40 |